The Variability in Urethral Stricture Management in the United States
By: Phillip J. Huffman, BA; Andrew J. Cohen, MD | Posted on: 01 Feb 2022
Urethral stricture disease (USD) is a common urological problem that drives many men to seek treatment from a urologist. Currently, treatment options include endoscopic management (eg urethral dilation or direct visual internal urethrotomy) and urethroplasty, with the latter being considered the standard of care by the AUA.1 Despite this recommendation, the ubiquitous implementation of urethroplasty is hindered by barriers such as variations among clinical sites, including in physician training, access to specialty care and patient populations.2 In order to overcome these barriers and promote care compliant with AUA guidelines, it is imperative the urologic community understand diverse urologic practice and how standards apply in real world situations.
One way to accomplish this goal is to utilize databases such as the AUA Quality (AQUA) Registry. The AQUA Registry collects information from 171 urology practices from all geographic regions, representing 48 states, 1,343 practitioners and 5,504,296 patients. The included practices are primarily community-based groups that range from single-provider to large organizations with dozens of urologists. The registry is derived from electronic health records and manual analysis of provider reports, and designed specifically to report health care outcomes.3
Our group aimed to quantify variation in USD care through the use of data from the AQUA Registry. In all, 77,742 patients in the registry had a history of USD diagnosis. These patients were separated into groups based on whether they were treated with urethroplasty alone (430), 1 trial of endoscopic management followed by urethroplasty (109), or ≥2 endoscopic treatments (repeat endoscopic management; 6,218). Independent variables included characteristics of the patient (eg age, race, ethnicity, comorbidities), provider (eg age, gender) and practice (eg metropolitan status, location and number of providers). The authors studied how variations in the aforementioned characteristics impacted treatment patterns in individual patients. Ultimately, older provider age, older patient age and higher patient comorbidities such as bladder cancer and benign prostatic hyperplasia were predictive for repeat endoscopic management. Practice variability was also evident when controlling for patient characteristics, as anywhere between 5% and 100% of patients at each studied practice underwent 2 or more endoscopic procedures. Additionally, patients were more likely to undergo repeat endoscopic management in 2018 compared to 2014, despite the AUA guidelines recommendation arguing against this in 2016.4
This study was the first of its kind published using the excellent resource of the AQUA Registry. Ideally, this database will thrive as a urology specific source for high quality, impactful research for decades to come. We highlight the need for continued quality improvement in USD care and suggest AQUA as a potential tool for promoting change. Given the unique population available to study, AQUA allows policymakers to meet providers where they are and address barriers to guideline-based care in the community. The findings of this study demonstrate that many urologists continue to pursue repeated endoscopic treatments, despite the wealth of evidence indicating the futility of such treatments.
While this study is novel in its use of the AQUA Registry, quality improvement research in urology is not limited to USD care. The Michigan Urological Surgery Improvement Collaborative (MUSIC) is a quality collaborative that comprises 42 practices representing 85% of Michigan urologists. MUSIC investigated baseline rates of bone and computerized tomography in prostate cancer patients in 2012 and 2013 before developing imaging criteria in 2014. Inappropriate use of both imaging modalities significantly decreased in 2015 and has remained stable, demonstrating the success of the initiative.5 Further, data from MUSIC registries were used to create a machine learning model that was able to accurately predict treatment decisions for men newly diagnosed with prostate cancer based on treatments for men with similar characteristics. This tool was made available online to help patients regarding the difficult decision of which prostate cancer treatment to pursue and improve their health care experience.6 These 2 studies show the potential for quality improvement projects to follow directly from registry-based study.
The state of USD treatment in the United States is currently heterogeneous and often noncompliant with recommendations from the AUA. Research is ongoing to explain this phenomenon and generate possible solutions. With further development, we suggest that AQUA would be a perfect tool for spreading awareness of the USD treatment guidelines to providers, reporting on continued treatment quality, and ultimately enhancing treatment outcomes for patients. Furthermore, we look forward to future research utilizing this powerful new tool developed by the AUA within reconstructive urology and beyond.
- Wessells H, Angermeier KW, Elliott S et al: Male urethral stricture: American Urological Association Guideline. J Urol 2017; 197: 182.
- Burks FN, Salmon SA, Smith AC et al: Urethroplasty: a geographic disparity in care. J Urol 2012; 187: 2124.
- Cooperberg MR, Fang R, Schlossberg S et al: The AUA Quality Registry: engaging stakeholders to improve the quality of care for patients with prostate cancer. Urol Pract 2017; 4: 30.
- Cohen AJ, Agochukwu-Mmonu N, Makarov DV et al: Significant management variability of urethral stricture disease in United States: data from the AUA Quality (AQUA) Registry. Urology 2020; 146: 265.
- Hurley P, Dhir A, Gao Y et al: A statewide intervention improves appropriate imaging in localized prostate cancer. J Urol 2017; 197: 1222.
- Auffenberg GB, Ghani KR, Ramani S et al: Ask MUSIC: leveraging a clinical registry to develop a new machine learning model to inform patients of prostate cancer treatments chosen by similar men. Eur Urol 2019; 75: 901.